Provider Demographics
NPI:1992920771
Name:KELLY, MICHELLE KRISTIN BURKE (PA-C)
Entity type:Individual
Prefix:
First Name:MICHELLE
Middle Name:KRISTIN BURKE
Last Name:KELLY
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:42 FAWN LN
Mailing Address - Street 2:
Mailing Address - City:KENNETT SQUARE
Mailing Address - State:PA
Mailing Address - Zip Code:19348-2311
Mailing Address - Country:US
Mailing Address - Phone:484-770-8091
Mailing Address - Fax:
Practice Address - Street 1:4745 OGLETOWN STANTON RD
Practice Address - Street 2:MAP 1 SUITE 128
Practice Address - City:NEWARK
Practice Address - State:DE
Practice Address - Zip Code:19713-2067
Practice Address - Country:US
Practice Address - Phone:302-733-4500
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DEC5-0000328363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant